Premature mortality in active convulsive epilepsy in rural Kenya

Anthony K Ngugi,Immo Kleinschmidt,Rachael Odhiambo,Gregory Fegan,Gregory Fegan,Josemir W Sander,Gregory Fegan,Christian Bottomley,Brian Neville,Rachael Odhiambo,Eddie Chengo,Gregory Fegan,Brian Neville,Eddie Chengo,Christian Bottomley,Christian Bottomley,Rachael Odhiambo,Eddie Chengo,Evasius Bauni,Christian Bottomley,Evasius Bauni,Immo Kleinschmidt,Rachael Odhiambo,Evasius Bauni,Christian Bottomley,Rachael Odhiambo,Immo Kleinschmidt,Brian Neville,Brian Neville,Eddie Chengo,Immo Kleinschmidt,Evasius Bauni,Charles R Newton,Gregory Fegan,Rachael Odhiambo,Evasius Bauni,Brian Neville,Eddie Chengo,Gregory Fegan,Gregory Fegan,Evasius Bauni,Evasius Bauni,Eddie Chengo,Christian Bottomley,Rachael Odhiambo,Evasius Bauni,Eddie Chengo,Rachael Odhiambo,Gregory Fegan,Immo Kleinschmidt,Eddie Chengo,Eddie Chengo,Gregory Fegan,Immo Kleinschmidt,Brian Neville,Immo Kleinschmidt,Christian Bottomley,Immo Kleinschmidt,Eddie Chengo,Christian Bottomley,Brian Neville,Gregory Fegan,Evasius Bauni,Evasius Bauni,Rachael Odhiambo,Rachael Odhiambo,Immo Kleinschmidt,Immo Kleinschmidt,Christian Bottomley,Christian Bottomley,Brian Neville,Brian Neville,Brian Neville

doi:10.1212/wnl.0000000000000123

Abstract

Objective:We estimated premature mortality and identified causes of death and associated factors in people with active convulsive epilepsy (ACE) in rural Kenya.Methods:In this prospective population-based study, people with ACE were identified in a cross-sectional survey and followed up regularly for 3 years, during which information on deaths and associated factors was collected. We used a validated verbal autopsy tool to establish putative causes of death. Age-specific rate ratios and standardized mortality ratios were estimated. Poisson regression was used to identify mortality risk factors.Results:There were 61 deaths among 754 people with ACE, yielding a rate of 33.3/1,000 persons/year. Overall standardized mortality ratio was 6.5. Mortality was higher across all ACE age groups. Nonadherence to antiepileptic drugs (adjusted rate ratio [aRR] 3.37), cognitive impairment (aRR 4.55), and age (50+ years) (rate ratio 4.56) were risk factors for premature mortality. Most deaths (56%) were directly related to epilepsy, with prolonged seizures/possible status epilepticus (38%) most frequently associated with death; some of these may have been due to sudden unexpected death in epilepsy (SUDEP). Possible SUDEP was the likely cause in another 7%.Conclusion:Mortality in people with ACE was more than 6-fold greater than expected. This may be reduced by improving treatment adherence and prompt management of prolonged seizures and supporting those with cognitive impairment.

Highlights

Mortality in people with active convulsive epilepsy (ACE) was more than 6-fold greater than expected
Epilepsy is one of the most common noncommunicable neurologic conditions in the world, estimated to affect approximately 70 million people, with up to 90% living in low- and middleincome countries (LMICs).[1]
It is associated with premature mortality, 1.3–9.3 times that of the background population in high-income countries (HICs) and much higher in institutionalized people and those with cerebral malformations.[2,3]

Summary

Methods

In this prospective population-based study, people with ACE were identified in a crosssectional survey and followed up regularly for 3 years, during which information on deaths and associated factors was collected. Age-specific rate ratios and standardized mortality ratios were estimated. Poisson regression was used to identify mortality risk factors. The study setting and population characteristics have been described previously.[17,18,19] Briefly, the study was within the Kilifi Health and Demographic Surveillance System (KHDSS) Kemri-wellcome.org/khdss/) in the Kilifi District of Kenya. In 2008 there were 233,800 people in the study area.[20] Households were mapped using global positioning system, and maps were used to locate and follow up participants. Field personnel conduct re-enumeration and vital status updates of the population register 3 times per year

Results

Discussion

Conclusion